Why the scourge of alcoholism defies a cure

The titillating gossip this week might be all about the latest Hollywood celebrity to fall off the wagon and get arrested for alleged drunken driving just weeks after completing a stint in rehab.

But for millions of ordinary Americans struggling to free themselves from alcohol addiction, the story of star Lindsay Lohan inspires not self-satisfied tut-tutting but rather a grimly familiar dread.Despite decades of research and dozens of treatments, alcoholism, America's most common addiction, remains notoriously difficult to overcome.

More than 30 percent of U.S. adults have abused alcohol or suffered from alcoholism at some point in their lives, according to a study released this month by the National Institute on Alcohol Abuse and Alcoholism, a branch of the National Institutes of Health.

Yet only a quarter of those afflicted received any treatment. And other studies show that, at best, only a quarter of those who seek treatment manage to abstain from alcohol for a year.

"Alcohol problems are not just something that affects Hollywood stars," said Dr. Robert Swift, a psychiatrist at Brown University who specializes in alcoholism. "We're talking about a chronic, relapsing condition. And we still have a long way to go in treatment. It's like treatment of cancer -- some people can be helped but others just cannot."

There are traditional "12-step" treatments for alcoholism, such as the program pioneered by Alcoholics Anonymous, that rely largely on peer support to encourage abstinence. There are a variety of behavioral and cognitive therapies employed by psychologists and psychiatrists to help patients avoid the triggers and thought-patterns that impel them to drink. There is a new generation of drugs to help curb an alcoholic's craving to drink.

And there are posh, inpatient rehabilitation centers -- the retreats of choice for infamous celebrities, disgraced politicians and other well-heeled alcohol abusers -- that sometimes sound more like spa resorts than rigorous treatment clinics.

But despite all that variety, experts say there is no unambiguous, foolproof treatment for alcoholism that ensures success.

That's because researchers are learning that alcoholism, like addiction to narcotics, causes permanent changes to the brain that can at best be ameliorated but never permanently undone. Moreover, scientists have discovered that some people are genetically more susceptible to develop alcoholism if they start drinking, just as some people are more likely to develop diabetes if they eat poorly and don't exercise.

"Once you become an alcoholic or a drug addict, you can't go back," said Swift. "It's something that becomes a chronic illness. So the idea that you go through rehab and you're cured is really kind of a ridiculous idea. You wouldn't expect that with diabetes, so why do people expect it with alcoholism?"

The scientific findings have begun to change the popular perception of alcoholism as a mere failure of will on the part of the drinker to stop drinking.

"The first drink may be volitional, but after one becomes addicted, it becomes a compulsion," said Ann Bradley, spokeswoman for the National Institute on Alcohol Abuse and Alcoholism. "Although we're always to be held responsible for our actions and their outcome, it's pretty fair to say that the most addictive drinking is well outside the control of the drinker."

For more than 70 years, since Alcoholics Anonymous was founded in 1935, complete abstinence from alcohol has been regarded as the only antidote to the disease of alcoholism -- and even then, alcoholics never regard themselves as "cured," but rather in a state of ongoing recovery or remission.

Just one drink, the theory went, and an alcoholic was destined to descend into a debilitating spiral of relapse.

But experts say that AA is successful for only about 1 in 5 alcoholics. And relapses are so characteristic of the disease that no other combination of drugs or therapy offers much better results, if the measurement is total abstinence maintained for at least a year.

So rather than discourage alcoholics by insisting on a goal many cannot reach, some addiction experts have begun changing the definition of success.

A 2005 study by the federal government's alcoholism institute determined that nearly 36 percent of U.S. adults suffering from alcoholism could be considered to be in "full recovery" after a year, if the definition of recovery was expanded to include not only complete abstainers (18.2 percent) but also "low-risk" drinkers (17.7 percent) who had managed to cut back, but not completely curtail, their alcohol consumption.

"There's a shift in the treatment approach toward being a little more flexible and being respectful of the patient's goals," said Dr. Edward Nunes, a psychiatry professor at Columbia University in New York and an addiction expert. "There are many patients for whom abstinence is still the best outcome and the one you should shoot for, but it's clear from clinical experience that there are some patients who can move from problem drinking back to a level of moderated drinking that's not problematic any more."

If that sounds to skeptics like moving the goal posts to make alcoholism treatment statistics look better, Nunes says that's not the intention of clinicians.

"When we're working with an individual patient, we're not worried about making the numbers look better," he said. "To me it's a question of how best to engage a patient. If a patient doesn't want to deal with [complete abstinence] right off the bat, it may be better to go with them a certain distance in order to build a relationship."